A Historical Perspective

Few nurses...have practical experience providing care during an epidemic, or other large scale disaster, that may involve hundreds of individuals who require care under unusual conditions.

Few nurses in North America outside of the Gulf Coast have practical experience providing care during an epidemic, or other large scale disaster, that may involve hundreds of individuals who require care under unusual conditions. Although Canadian nurses in Toronto had this experience during the 2003 outbreak of SARS, care was generally offered in typical hospital rooms (Bournes & Ferguson-Pare, 2005). Pictures from the 1919 influenza epidemic show a different experience, with nurses, both paid and volunteer, caring for large numbers of patients placed on cots in rooms more reminiscent of barns than wards (Groft, 2006; Starr, 2006). In the pre-antibiotic era, the major response to any large disease outbreak was comfort and support until the disease ran its course. In the late 20^th century, such was the initial response to what we now know as HIV and AIDS. In cities where this epidemic struck early, large numbers of seriously ill patients were admitted to hospitals for the purpose of receiving good, basic nursing care, as this was all that could be done in the absence of any definitive treatment (Davis, 1999).

Wartime has also added to our understanding of health and human caring and response to emergencies and disasters. Nurses contributed to this learning, as well as the caring and response. The origins of nursing as we know it today are often traced to the Crimean War experiences of Florence Nightingale and others associated with the British army. Long histories and many Nightingale biographies have dissected this key event. For purpose of this overview, suffice it to say that the presence of a cadre of disciplined nurses committed to cleanliness and comfort allowed more ill and injured soldiers to survive than would otherwise have been the case. Perhaps more significant is the later contribution of Miss Nightingale to the decrease in morbidity and mortality of the wounded soldiers through the application of basic statistical analysis, infection control measures, and what we would now consider quality improvement procedures. (Garfield, Dresden & Rafferty, 2003). In the United States, the Civil War is cited regularly for the role of volunteer nurses and for the stimulus it gave Clara Barton to organize the American Red Cross, which she eventually accomplished in 1881.

By World War II, formally organized nursing services had become a part of the military...[whose] contribution to higher levels of care later translated to more sophisticated civilian emergency care...

Nursing became a specific Red Cross service in 1909 (Evans, 2003). While the military employed physicians (vivid descriptions of battlefield amputations abound), nurses were not considered essential members of the military health care team until the 20^th century (Holder, 2004a). Even at the time of the First World War, the hospital units that traveled to Europe to support the American Expeditionary Forces were composed of volunteer units, consisting of physicians and nurses from hospitals or communities coming together to fill the essential need for a health presence during and after battle (Holder, 2004b).

By World War II, formally organized nursing services had become a part of the military, and the Cadet Nurse Corps was organized to quickly speed professional nurses through nursing school and into service (Leone, 1987). Questions at the time included what rank should these nurses be given and how should men in the profession should be treated. Nurses in the military often had first exposure to the advances in health care that wartime exigencies stimulated, such as the use of penicillin, the use of triage, and advanced trauma care. The military contribution to higher levels of care later translated to more sophisticated civilian emergency care; for example MASH units and the ‘golden hour’ rule for rapid trauma care translated into civilian level regionalization of pre-hospital and trauma systems around the country (King & Jatoi, 2005).

Later 20^th Century Developments

By the mid-20^th century, it was not unusual for a hospital to have an ‘emergency room’ that was primarily a place for suddenly arriving injured patients to be examined and offered initial treatment. These units frequently did not have full-time nursing staff, but were rather staffed by an on-call nursing supervisor when services were needed. The lessons learned from mid-century wars illustrated that immediate and dramatic efforts could save many more lives. Soon the emergency room evolved into the fully staffed emergency department, ready to receive patients at any hour of the day or night with the essential cadre of full time nurses. Just as emergency medicine became a distinct specialty within medicine, emergency nursing began to identify the skills and abilities that set them apart. The Emergency Department Nurses Association (the predecessor to today’s Emergency Nurses Association [ENA]) was formed in 1970. Today, ENA has emerged as an influential national body that supports education and specialty certification for those nurses ready to care for the victims of emergency or disaster events (ENA, 2006; Frank, 2000).

The network of modern communications represented by worldwide news services, such as the British Broadcasting Company or Reuters, has also made nurses in the United States increasingly aware of the range of natural disasters and population displacements that occur around the globe. Nurses are a part of the response mounted each time there is a report of a weather or geological event, such as an earthquake, flood, or tsunami. Many faith-based organizations are ready to move on short notice to serve those in need, and nurses are among the volunteers they count on to respond. Beyond the many emergencies caused by forces of nature, there is the continuing public health emergency created when populations are displaced by war, political conflict, and/or civil strife. In addition, the world is now facing the prospects of an increased incidence of terrorism events, including biological, mass casualty, and chemical agent use. Several organizations are very active in providing care to populations displaced for what ever reason, including the International Committee of the Red Cross (ICRC) (www.icrc.org/), the International Rescue Committee (IRC) (www.theirc.org/), and in the United States, the American Red Cross (ARC). Nurses who are prepared to provide primary health care under these challenging conditions are regularly recruited to be part of the response teams for these agencies. At the IRC, a nurse is a key staff member behind the rapid establishment of refugee camps for those who need shelter.

Nurses have historically played important roles in everyday, local public health emergencies (Kennedy, 2002; Parke & Parke, 2005; Rowney & Barton, 2005). When a community is challenged by overwhelming wind, water, snow, or mud, and many families and individuals are isolated by downed trees, power outages, or washed out-roads, public health nurses work systematically to be sure that no one is abandoned, often traveling with public works crews for access to isolated areas. As an emergency leads to the establishment of temporary shelters (often in gymnasiums, schools, or other large spaces), public health nurses are routinely assigned to assist in triage and screening for health problems, administration of first aid and psychological support, implementation of infection control procedures, and monitoring so that the congregate living situation does not lead to an outbreak of disease. Nurses have always been key players during epidemic situations by performing contact tracing and conducting case investigations, engaging in surveillance and reporting, collecting specimens, administering immunizations, and educating the community. It is safe to say that just about any kind of emergency in the community has the potential to impact the public’s health; and nurses are needed for prevention, surveillance, and response of every type.

National Thinking about Emergency Preparedness

At the end of the 20^th century, national thinking about emergency preparedness led to two important developments: identification of the key competencies needed by health care providers for effective emergency response, and increased attention to planning for and practicing emergency response. While there was a dramatic increase in both attention and funding following the 2001 World Trade Center and U.S. Pentagon attacks and the Anthrax events, these emergency preparedness activities were well underway prior to that time.

Effective response requires a disciplined team in which each participating individual follows clear lines of communication and performs according to clearly assigned role directions.

Responding to emergencies is far more than knowing how to identify the signs and symptoms of traumatic injury or exposure to hazardous chemicals. Effective response requires a disciplined team in which each participating individual follows clear lines of communication and performs according to clearly assigned role directions. The lessons leading to this statement emerged in part from the lessons of firefighting when multiple fire companies respond to the same large conflagration, as well as the important influence of military medicine on emergency response. During the 1970’s the incident command system was developed for first responders, and later adapted for hospital use (National Incident Management System [NIMS], 2004).

Since most health professionals do not respond to emergencies every day, it was necessary for nursing to identify the core abilities needed to become a part of an emergency response team and perform well. To that effect, the International Nursing Coalition for Mass Casualty Education (INCMCE) (Vanderbilt University, 2003) was established to take on the task of clarifying exactly what should be included in the undergraduate nursing curriculum to assure communities that their professional nurses were competent to respond when needed. The Appendix provides a summary of competencies for professional nurses suggested by INCMCE. The complete curriculum outline is available from the organization’s website.

Similar efforts were begun in public health, where nurses form the largest of this health sector’s professional groups. At present there are competency sets identified for many other health professionals and settings. These competency sets provide a template for assuring that nurses are ready to respond wherever they may practice. Table 1 lists the competencies for public health workers, while Table 2 provides a list of the currently available emergency response competency sets applicable to nursing and the source from which they can be accessed in their entirety.

Table 1. Core competencies for ALL public health workers*

Describe own professional role in a range of emergencies Describe the agency chain of command Identify and locate the agency emergency response plan Describe own functional role and responsibilities in emergency response and demonstrate abilities in regular drills Demonstrate correct use of communication equipment Describe role in emergency communication: within agency, with media, general population and family Identify limits to own knowledge, skills and authority Apply creative problem solving skills Recognize deviation from the norm and describe appropriate action to report findings

* Source: Columbia University School of Nursing, Center for Health Policy. Available at: www.cumc.columbia.edu/dept/nursing/institutes-centers/chphsr/compbroch.pdf

Table 2. Emergency preparedness competency sets
Competency set	Website
Core Bioterrorism and Emergency Readiness Competencies for ALL Public Health Workers	www.nursing.hs.columbia.edu/institutes-centers/chphsr/btcomps.pdf
Annotated Emergency Preparedness Competencies for Public Health Leaders and Administrators	www.cumc.columbia.edu/dept/nursing/institutes-centers/chphsr/Leader.pdf
Annotated Emergency Preparedness Competencies for Public Health Professionals	www.cumc.columbia.edu/dept/nursing/institutes-centers/chphsr/Prof.pdf
Annotated Emergency Preparedness Competencies for Public Health Technical/Support Staff	www.cumc.columbia.edu/dept/nursing/institutes-centers/chphsr/Tech.pdf
Clinician Competencies During Initial Assessment and Management of Emergency Events	www.nursing.hs.columbia.edu/institutes-centers/chphsr/clinician-comps.pdf
Educational Emergency Preparedness Competencies for Registered Professional Nurses	www.mc.vanderbilt.edu/nursing/coalitions/INCMCE/educomps.pdf
Emergency Preparedness and Response Competencies for Hospital Workers	www.nursing.hs.columbia.edu/institutes-centers/chphsr/hospcomps.pdf

By the year 2000, both hospitals and health departments began to realize that their level of attention to emergency drills or exercise was inadequate to assure that they were ready to participate...All agencies now recognize that a response requires an inter-agency, interdisciplinary response...

By the year 2000, both hospitals and health departments began to realize that their level of attention to emergency drills or exercises was inadequate to assure that they were ready to participate in inter-agency response for all types of emergencies. Recently, community-wide efforts to link all potential responders into a coherent system have intensified, with efforts to bring not just hospital emergency departments but the full range of health resources to responding agencies. Under the National Incident Management System (NIMS), all sectors of health care, as well as other responders, are required to utilize a common incident management/response system. The NIMS plan is an evolving document, and can be readily accessed through the Federal Emergency Management Agency (FEMA) Emergency Management Institute website (FEMA, 2006a). Nurses will need to be thoroughly versed in NIMS and the incident command system (ICS) and be personally and professionally prepared to respond to any type of emergency event. All across the nation all levels of first responders (fire, police, Emergency Medical Services, and public health) and first receivers (hospitals, emergency departments, and community centers) are planning, practicing, drilling, and exercising together.

Under the NIMS, all sectors of health care, as well as other responders, are required to utilize a common incident management/response system.

All agencies now recognize that a response to any sort of emergency requires an inter-agency, interdisciplinary response, and that nearly all emergencies have potential health consequences.

As the new century has unfolded, the devastating impact of Hurricanes Katrina and Rita on the Gulf Coast of the United States, the heat wave of the summer of 2006, and the threat of new emerging infectious diseases illustrate the need for hospitals, nursing homes, community clinics, health departments, and all other agencies dependent upon nursing staff for effective performance, to be prepared. Advance planning is needed for both surges of incoming patients and the possible evacuation of all patients, as well as the provision of care when staff themselves are experiencing dislocation, illness among themselves or their family, fears and concerns for their own and their family’s safety, or other disaster impacts.

Roles Filled and Being Filled by Nurses

All nurses must be prepared to report to work during a disaster.

Nurses will continue to be key players in local and national level emergency response as we move through the 21^st century. As members of the community, the basic emergency preparedness of nurses can be an example to other members of the community. All nurses must be prepared to report to work during a disaster. Studies have shown that the most common barriers to a health care worker’s ability to report to work during an emergency are child, elder, and pet care obligations, and transportation, while the most frequently cited barriers to willingness are fear and concern for one’s self and their family (Qureshi, Gershon, Gebbie, Straub, & Morse, 2005). Each nurse should have a family emergency plan that is reviewed with all family members, and a personal emergency plan that delineates the steps to be taken to assure that family obligations are provided for in the event s/he is called upon for emergency work. Copies of a family disaster plan may be accessed from the Federal Emergency Management Agency (FEMA, 2006b) web site. In addition, nurses need to have a go-pack that contains the essential personal supplies ready in the event they do have to respond. Table 3. lists the typical contents of a go-pack, however the contents must be adjusted based upon the role that the nurse will assume in the relief efforts, geography/location of the event, season and climate of the region, and expected duration at the site. At the time of deployment each relief agency will issue a list of personal items to be taken by responders.

Table 3. Suggested supplies for a volunteer personal go-pack*

Acetaminophen or Ibuprofen Cell phone with charger Clothing (layered, appropriate for work to be done and climate, with extra underwear) Emergency contact information Energy bars Eye glasses / sun glasses First aid kit (simple) Flashlight with extra batteries Hand sanitizer gel Identification, including volunteer card and drivers license Local map (if traveling within the affected community) Medical equipment i.e.: stethoscope, portable b/p machine, etc. Pens / markers Personal medications (adequate supply for duration of assignment) Plastic bags Radio (small, battery operated) Rain gear Shoes or boots (appropriate for terrain, comfortable, well broken in) Sunscreen Small amount of emergency cash in small bill denominations Tissues Toiletries, including toothpaste, toothbrush, shampoo, deodorant, comb/brush Vaccinations (be sure to be appropriately vaccinated for region/event), bring vaccination card with you Wet wipes Whistle *Pack all items in a soft duffel that is easy to store and transport.

*Note: List needs to be adjusted based upon the role that will be performed, geographical area of the relief effort operation and season of the year.

In hospitals and health departments, nurses are among the most flexible of staff. They often possess key clinical care, communication, and management skills that can be used to fill a wide range of roles under emergency circumstances. One of the emerging issues in disaster preparedness is the balance between knowledge of how emergency response works as a system, in contrast with knowledge of signs, symptoms, and clinical management of the injuries and illnesses caused by the many specific agents of disasters. The amount of training time needed to remain clinically skilled in rare conditions is prohibitive in most settings beyond the emergency department. This means that training in how to respond within the system is critical; basic competency training is essential; and systems need to be in place to provide

...training in how to respond within the system is critical...

just-in-time training for particular, less common scenarios or problems, given the specifics of the event. One emergency department leader in a large hospital system has indicated his preference for nurses rather than physicians in the key incident management roles within a hospital, based on their grasp of the need for staff who can work within the system and maintain order (Silber, personal communication, January 2005).

As hospitals and communities plan more comprehensively for a range of disaster events, it has become clear that nurses are key for meeting surge capacity needs, whether these needs are in the field conducting surveillance, in shelters or mass medication/vaccination dispensing sites, in departments of health staffing public education/information hot lines, or in hospitals that are rapidly admitting patients in numbers far exceeding the typical census. In order to meet this surge demand for nursing services, registers of nurses prepared to be deployed where needed are being developed by many state level nursing associations, boards of nursing, and state public health agencies. Further, nurses are being recruited into Medical Reserve Corps (MRC) units in communities across the country (The Office of the Surgeon General, 2006). Medical Reserve Corps Units aim to assist with filling local surge capacity needs for both public health and acute care agencies. In many communities recruitment into the MRC has emphasized those health professionals not currently employed, whether because of retirement or other reasons, but who would like to serve their communities in a time of emergency. The MRC was conceived as a part of citizen activism that can take full advantage of the interest that many people have in serving where they live and work. Newly specified competencies for MRC members focus on readiness for action, family preparedness, and capacity to function within a local incident response system.

Opportunities for volunteerism on a broader scale are also available, with many nurses participating in the National Disaster Medical System (NDMS) (U.S. Department of Homeland Security, 2006). The NDMS units are fully operational, mobile teams ready to provide ‘state of the art’ medical care under any conditions at a disaster site, in transit from the impacted area, and into participating definitive care facilities. These teams practice together frequently, and are regularly deployed to emergency zones or sites of large events which might require health support, such as the Olympic Games or a presidential inauguration. Many NDMS nurses served in the Gulf regions following Katrina and Rita. It should be noted that NDMS units were created to travel to locations where their services are needed, while MRC units are intended to provide immediate local assistance. Nurses are key players in both services.

Nurses are also looked to as planners and policy-makers at many levels of the emergency response system. The list of nurses engaged would include U.S. Public Health Service officers working within the Departments of Homeland Security and Health and Human Services. Nurses are essential to the coordination of all health sector planning for emergencies under the national planning system put in place through Homeland Security. At the state and local level in public health, state public health nursing directors are providing leadership in identifying training needs and coordinating with the American Red Cross regarding improvements in health services in emergency shelters. Of particular concern to this group is the development of improved standards for what are called special needs shelters, those serving persons with physical, mental, or emotional limitations needing special attention during emergencies. Finally, within hospitals and community health centers, nurses are frequently assigned to emergency planning committees and councils, or are asked to develop the site-specific emergency plans.

Conclusion: Nurses Are Key

Whatever emergency challenges this century continues to present, nurses and nursing will be there to respond!

Without attempting to present an exhaustive listing of activities performed by nurses in emergencies, this discussion has highlighted the historic and current involvement of nurses in response to emergencies, whether caused by humans or by natural forces. The fundamental goal of nursing, to assist individuals to their highest possible level of functioning in the face of health and illness challenges, is never more needed than under emergency conditions. While an emergency does not allow the luxury of long-term planning or extensive patient education on health promotion, the skills and abilities of nurses can assure prompt triage, essential nourishment, relief from physical and emotional pain, and support while planning for personal and family actions to resume ordinary routines of life. With our improved understanding of the need for competency in emergency response, nurses are receiving better basic and continuing education and are practicing their roles in hospital, public health, and community drills. Whatever emergency challenges this century continues to present, nurses and nursing will be there to respond!

Authors

Kristine M. Gebbie, DrPH, RN
E-mail: Kmg24@columbia.edu

Kristine M. Gebbie is an experienced educator and public health practitioner. Her experience in emergencies includes work as director of public health in two states, including leadership during major natural disasters (e.g., Mt. St. Helen’s eruption) and deliberately caused emergencies (deliberately caused food-born salmonellosis outbreak and cyanide tampering with over-the-counter medication). She has conducted research leading to identification of competencies in emergency preparedness for public health workers, clinicians, and hospital workers.

Kristine A. Qureshi, DNSc, RN
E-mail: kqureshi@hawaii.edu

Kristine A. Qureshi has experience both as a clinician and as a leader in New York City emergency departments. She has been a part of Centers for Disease Control and Prevention and Health Resources and Services Administration-funded emergency preparedness training programs at Columbia University and Adelphi University. She has been a co-investigator in major projects examining worker willingness and ability to report to work in emergency situations and evacuation of workers from high-rise construction.

Appendix. Summary of emergency preparedness competencies for registered nurses responding to Mass Casualty Incidents (MCI) events*
CORE COMPETENCIES
Critical Thinking	Use an appropriate framework to support decision-making and prioritization Use sound clinical judgment to assess needs for immediate care and ongoing care Describe essential nursing care for individuals, families and communities during all phases of event Describe triage procedures for MCI
Assessment	General: Assess safety issues for self, responders and victims Identify indicators of a mass and individual exposure to (chemical, biological, radiological, nuclear, and explosive (CBRNE) agents/events Demonstrate ability to access current, accurate information re CBRNE agents/events Describe essential items for MCI scene assessment Identify groups more vulnerable to the effects of MCI Specific: Conduct a focused health history to assess for CBRNE exposure Perform an age appropriate assessment Assess immediate and long term psychological response of individual, family and community to an MCI event Identify available resources psychological services Describe psychological impact on responders and health care team
Technical Skills	Demonstrate ability to administer medications and immunizations via all routes Demonstrate knowledge of nursing interventions for medication adverse effects Demonstrate ability to perform basic therapeutic interventions, including: first aid, wound care, oxygen therapy, urinary and gastric catheter insertion, lavage (gastric, wounds, and eyes) Identify need and implement isolation and decontamination for CBRNE events Demonstrate knowledge and skill for selection and use of respiratory and level B and C personal protective equipment Implement fluid/nutrition therapy Assess, prepare, care, monitor and maintain safety during patient transport Demonstrate use of communication equipment and information management techniques
Communication	Describe chain of command and management system in use by agency Identify own role in the emergency response system and at place of employment Locate and describe own agency emergency plan Discuss security and confidentially during MCI response Demonstrate ability to document Identify appropriate resource for inquiring parties Describe basic principles of risk communication Identify likely psychological reactions to the event Describe appropriate coping strategies
CORE KNOWLEDGE
Health Promotion, Risk Reduction, Disease Prevention	Identify potential threats and the effect on public, emergency and health care systems Describe public health issues related to MCI events: water, air, food, shelter, and displaced persons and strategies to limit exposure
Health Care Systems and Policy	Define and distinguish terms: disaster and MCI Define terms: CBRNE, weapons of mass destruction (WMD), triage, chain of command, personal protective equipment (PPE), scene assessment, emergency management Describe four phase of emergency management Describe local emergency response system Explain interaction of local, state and federal emergency response systems Explain the emergency powers of public health Explain how to manage an MCI crime scene: chain of custody, integrity of evidence Recognize how an MCI may tax resources and know how to obtain adequate supplies
Information and Health Care Technologies	Describe use of emergency communication equipment Discuss principles of containment and decontamination Describe procedures for decontamination Describe how nursing skills may have to be adapted while wearing PPE
Ethics	Identify and discuss ethical issues related to MCI events Describe the psychological and ethical issues surrounding care for the dying and the deceased Identify and discuss issues related to: abandonment, reporting during the event, volunteers
Human Diversity	Discuss the social and cultural issues related to individual response to an MCI Discuss the diversity of human response to terrorism
PROFESSIONAL DEVELOPMENT
Roles of the Nurse	Describe the variety of roles that nurses may play in MCI management and response Identify the most likely role for ones self Identify limits to one’s own ability/skills/authority List essential equipment for responding (personal and patient care) Recognize importance of maintaining expertise and knowledge Participate in drills at place of employment and in own community

* Source

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